Acute Limp Flashcards
What is antalgic gait
Shortening of the stance phase and prolonging of the swing phase, as the child ‘hurries’ off one leg to offload the source of pain (most common, usually trauma or infection)
What is trendelenburg gait
pelvis exhibits a downward tilt towards the unaffected side during the swing phase due to weakness in the contralateral gluteus medius muscle (DDH, Perthes’ disease, SCFE)
What is steppage gait
excessive flexion of the hip and knee joints during the swing phase due to an inability to dorsiflex the foot (Cerebral palsy, neurological disorders)
What is vaulting/circumduction gait
hyperextension and locking of the knees at the end of the stance phase and the child vaults over the extremity (limb-length discrepancy, mechanical disorder causing abnormal knee mobility)
What are the causes of acute limp
Transient synovitis
DDH
Fracture
Infection – septic arthritis, osteomyelitis of hip or spine
Overuse injuries
Perthes disease (acute)
Juvenile idiopathic arthritis (JIA)
Osteochondritis dissecans of the knee
Trauma – accidental/non-accidental
Malignant disease – leukaemia, neuroblastoma, bone tumours
What are the causes of chronic limp
DDH
Talipes
Neuromuscular, e.g. cerebral palsy
Juvenile idiopathic arthritis (JIA)
Tarsal coalition
Slipped capital femoral epiphyses
What features suggest an organic cause of limp
Occurs day and night
Interrupts play
Pain located in the joint, unilateral
Weight loss, fever, nights sweats
Rash
Diarrhoea
Point tenderness
Redness
Swelling
Limited movement
muscle weakness of atrophy
Lymphadenopathy
What features suggest a non-organic cause of limp
Only occurs at night, primarily on school days
No interference with normal activities
Located between joints bilateral
Otherwise healthy
What are the red flags for urgent referral to paeds for a limp
<3yo
>9yo with painful or restricted hip movements (internal rotation esp.)
Unable to weight bear
Fever and/or signs: pain causing night-waking, fatigue, anorexia, weight loss, night sweats
Severe pain, agitated, reduced peripheral pulses
Muscle weakness/sensory impairment
Suspicion of NAI
What investigations should be done for a limp
Bloods: FBC, plasma viscosity, ESR/CRP, muscle enzymes
Other
- X-ray of affected joint
- Bone scan
What is transient synovitis and its epidemiology
Acute hip pain associated with a viral infection
2-12yo
Most common cause of acute pain in children
What are the signs and symptoms of transient synovitis
Preceding viral illness
Sudden onset pain in the hip or a limp (may refer to knee)
No pain at rest
Decreased range of movement, particularly internal rotation
Mild fever or afebrile BUT does not appear ill
What is the management for transient synovitis
Any limp + fever → urgent specialist assessment
Once diagnosed: self-limiting
Bed rest
Pain relief e.g. paracetamol, ibuprofen
resolves after a few days (refer if >1 week)
What is Kocher’s criteria
indicates septic arthritis over transient arthritis:
Temperature > 38.5oC
Refusal to weight bear on affected limb
Raised inflammatory markers à ESR > 40mm/hour, CRP > 20mg/L
WCC > 12 x 109/L
Describe growing pains
Organic disease has been excluded
May be caused by oedema in the fascial sheaths
3-6yo
Pain at night, often after a day of vigorous activity
headaches and abdominal pain may also be experienced
Should NOT cause a limp
What could Nocturnal wakening with leg pain indicate and what are the other features
Growing pains (normal)
Osteoid osteoma (normal)
+ anaemia, bruising, irritability, infections: leukaemia, lymphoma, neuroblastoma
What could a clunk on hip movement in neonates indicate and what are the other features
DDH (older infant, asymmetrical upper leg skin folds, limited hip abduction)
What could febrile, toxic-looking infant with irritability on nappy changing with joint pain suggest and what are the other features
Septic arthritis (raised WCC/CRP/ESR)
Osteomyelitis
Both show restricted joint range (esp. hip) or limb movement
What could Sudden limp in an otherwise well child indicate and what are the other features
Transient synovitis
Perthes disease
Both may show unilateral restricted hip movement
What could Fever, erythematous rash, red eyes, irritability in infant/young child with a limp indicate and what are the other features
Kawasaki disease (erythema/oedema of hands and feet, oral mucositis, cervical lymphadenopathy)
What could irritability, fever and reluctance to move in an infant/young child with limp indicate and what are the other features
Discitis (stiff back, tripod sitting)
Vertebral osteomyelitis
What could hip pain in adolescent boys indicate and what are the other features
SUFE (unilateral hip restriction)
What could Lethargy, unwillingness to do physical activity, irritability and rash indicate in children with a limp and what are the other features
Juvenile dermatomyositis (eyelid erythema, proximal muscle weakness
What could lethargy, arthralgia, constitutional symptoms with limp indicate and what are the other features
Juvenile onset SLE (multisystem abnormalities, haematuria, facial erythema)
